AmSECT Quality and Outcomes Conference Patient Blood Management: A Wise Investment for the Patient and the Health System Miriam A. Markowitz, CEO October 2, 2014, 1:45pm 2:10pm
AABB Introduction 2
Emerging Paradigm Shift: Transfusion Medicine Industry & Practice 3 rd level paradigm in blood transfusion marketplace Technology development advancing collection and storage knowledge: computer chips, software, nucleic acid testing, pathogen reduction strategies From Do No Harm to Safe and Effective to Better Transfusion Outcomes A new set of demands require a response Raymond Goodrich, PhD, CSO Terumo BCT 4
Patient Blood Management (PBM): A Working Definition "Patient blood management (PBM) is an evidence-based, multidisciplinary approach to optimizing the care of patients who might need transfusion." 5
Patient Blood Management (PBM): Another Working Definition The application of evidence-based medical and surgical concepts to achieve measurable improvements in patient safety and clinical outcomes using an interdisciplinary care team to optimize: hemoglobin hemodynamic stability tissue oxygenation hemostasis in a patient-specific manner. 6
Current Health Care Context: PBM s Role Triple Aim Goals Improving the patient experience of care (including quality and satisfaction) Improving the health of populations Reducing the per capita cost of health care Patient Blood Management Programs Improve Patient Outcomes Improve Patient Safety Drive out Overuse & Waste Reduce Practice Variation Improve Clinical Decision Making Drive Patient-Centered Care 7
Annual Cost to US Health Care System in 2011 ($ in Billions) Health Care Waste Categories Low High Overtreatment 158 226 Administrative complexity 107 389 Failures of care delivery 102 154 Pricing failures 84 178 Fraud and abuse 82 272 Failures of care coordination 25 45 Total 558 1263 % of Total Spending 21% 47% Berwick, D., Hackbarth, A. - JAMA, April 11, 2012 Vol 307, No. 14. 8
Comprehensive Patient Blood Management: What is Possible? Improved patient outcomes Increased Net Revenue from Pre-Emptive, Patient- Centered Strategies 40-50% reduction in transfusion for cardiac surgery Reduction in Practice Variation Improved Care Coordination 10 Ereth, et al, ASA Abstracts, 2013
Patient Blood Management Program Leadership Performance Management Accountability Systems Education Health Information Patient Flow Management Infrastructure Clinical Experts 12
Comprehensive PBM Components Informatics Change Management Clinical Decision Support Education 13
AABB s PBM Standards Structure: Activity Based 14
Improved Blood Utilization Using Real-Time Clinical Decision Support #1 Conclusion: Real-time CDS has significantly improved blood utilization. Overall estimated net savings for RBC units (@$225/unit) acquisition costs 2012 over 2009 $1.6m Results: % of blood ordered w/ patient Hb levels > 8g/dL August 2009 Range: 57% - 66% July 2010 Range: 52% - 66% (Education Initiative) December 2010 Range: 35% (CDS & BPA Initiative) Post 2010 Range: 30% TRANSFUSION Volume 54, May 2014 17
Improved Blood Utilization Using Real-Time Clinical Decision Support TRANSFUSION Volume 54, May 2014 18
Improved Blood Utilization Using Real-Time Clinical Decision Support Change Management Practice & Tools Blood utilization clinical effectiveness team Real-time CDS deployed within EMR system Best practice alert vetted via wide approval process, within quality & safety structures Strong educational initiatives TRANSFUSION Volume 54, May 2014 19
Blood management: Reducing blood use reduces risks and lowers costs #2 2007 => 2009 Program Interval Saved $2.9M implementing program 2 Unit => 1 Unite ordering policy (hospital-wide) Lowered Hemoglobin Trigger 10 g/dl => 7 g/dl Sustained Savings reports, almost 50% drop in blood cost acquisition Clinical Research and Quality Improvement teams engaged OR Manager, Vol. 28 No 1, Jan. 2012 20
Fewer Transfusions, better outcomes #3 2010 => 2012 Program Interval 27% decline in overall blood transfusion, even with 20% increase of patient discharges. 19,000 transfusion units avoided CVS Program lowered transfusions by 50% 8% of procedures require transfusions, compared with 60% of cardiac surgeries nationally (2012) Kansas City University Medical Center, Advances, April 23, 2013 21
Maine Hospital Slashes Transfusions.. #4 60% reduction RBC transfusions 50% reduction Platelet transfusions 75% reductions Plasma transfusions 2 Unit => 1 Unit Orders Shift: 55% => 90% Overall Hemoglobin trigger: 8.5 => 7.8 $1.6M annual savings in blood acquisition Tools: Physician Education CPOE with alerts Physician Report Card Clinical Champion Patient Cohorts Maureen McKinney, Modern Healthcare, June 23, 2014 22
Next Generation Patient Blood Management #5 Risk Adjusted Blood Utilization Metrics Benchmarking and comps: how do you account for year after year and across hospital outcomes? How do you adjust across surgeons and physician practice? How do we consider reimbursement models for blood products acquisition? 2006-2012: Five Year Trend of 3 AMCs 244K hospitalizations Findings: Reduction in mean RBCs units used Increase in proportion of hospitalized patients transfused Highest RBC utilization/admission: SCT service, followed by cardiology, critical care Highest % of admissions receiving RBCs: Internal Medicine (14%), Hematology oncology (14%), orthopedic service (13%) No downward trend in #of RBCs/admission for surgical services, cardiology, nephrology 23
Next Generation Patient Blood Management #6 PBM Success Dependent on Institution-Wide Change in Transfusion Practice 2011 over 2006: RBC units transfused decreased 27% overall Pre-PBM.96 units per patient discharged vs..55 units per discharge Pre-PBM 62% RBC transfusions ordered for surgical patients Post-PBM 57.5% Success attributed to Hospital Wide physician buy-in re restrictive transfusion approach. Guidelines Benchmarks Clinical Co-Chair to BUC now, BUManagementC 2 => 1 unit Transfuse and Assess Total N of units decreased; Total N of transfusion episodes did not 24
How Do You Build PBM Program? Determine Clinical Variation, Get Specific Detect Where You Are Develop New Tools for Old Problems & Shamelessly Adopt Others Tools and Resources Determine Where You Want to Go Set Targets Anchor within larger hospital quality, risk, financial goals 25
When does Wise Investments Pay Off? #1 Right Skill Sets in Place Clinical Know-How Change Management Program Management Performance Measurement Executive Leadership #2 Incentives are Aligned Program Goals and Larger Institutional Goals ACO Compatibility #3 Impact is Measured Data, Information, Feedback, Hemovigilance & Adverse Reporting, Benefits Outcomes Reporting 26
Transfusion Expenditures Cost-Effective Expensive Patient Blood Management: Health Systems Impact Previous Transfusion Activities Future Transfusion Activities Safe and Beneficial Transfusion Outcomes Clinical Variation & Non-Evidence Based
Take Home Message Read the literature Engage in research Pursue hemovigilance activities via PSO Do the math Get patient specific Get surgeon specific Anchor efforts within larger health system frame Get out of the surgical suite and share your expertise. 28
Thank You Questions? Contact: mamarkowitz@aabb.org Office: 301-215-6583 29